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Psoriatic Arthritis Handbook
Managing Psoriatic Arthritis: Treatments and Lifestyle
How is psoriatic arthritis treated?
While there is no cure for psoriatic arthritis, there are multiple drug treatment options that work to control the disease and its symptoms (3). Drug treatments specific for psoriatic arthritis focus on:
DRUG TREATMENTS
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slowing down the progression of the condition;
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reducing inflammation;
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relieving pain;
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treating skin symptoms;
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keeping joints as mobile as possible.
For most people, treatment for psoriatic arthritis will involve trying several different medications. Since many people with psoriatic arthritis have psoriasis, managing the condition can seem like treating two diseases. Some treatments work on both diseases, while others work mainly on the arthritis or skin problems.
Every person diagnosed with psoriatic arthritis is different. Doctors recommend certain treatments depending on:
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how many and which parts of the body are affected;
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how severe the disease is;
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drug allergies and other health conditions;
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current medication use.
Many times, people with psoriatic arthritis may need to take more than one drug at the same time to control the disease – this is called combination therapy. Combination therapy can allow for lower doses of each individual drug to be used.
During flares, additional medications may be added temporarily or for the longer term.It is important to be involved in shared-decision making with your doctor(s) and adhere to the treatment plan. You should communicate any issues with medications, such as side effects or difficulty adhering to the treatment plan, so that effective steps can be taken to address the problem(s).
TREATMENT FOR THE ARTHRITIS
The over-the-counter and prescription medicines for psoriatic arthritis include:
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non-steroidal anti-inflammatory drugs (NSAIDs);
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steroid medication (corticosteroids);
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disease modifying anti-rheumatic drugs (DMARDs).
Non-steroidal anti-inflammatory drugs (NSAIDs)
NSAIDs can help relieve pain and reduce inflammation, but they might not be enough to treat symptoms of psoriatic arthritis (9).
There are two types of NSAIDs:
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traditional NSAIDs, such as ibuprofen, naproxen, and diclofenac;
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COX-2 inhibitors, such as celecoxib and etoricoxib.
Like all medicines, NSAIDs can have side effects. Your doctor will take precautions to reduce the risk of side effects by prescribing the lowest dose necessary to control your symptoms for the shortest time possible.
NSAIDs can sometimes affect the stomach and intestines, causing digestive problems such as indigestion and stomach ulcers (17). A medication called a proton pump inhibitor (PPI), such as omeprazole or lansoprazole, may also be prescribed to help protect the stomach.
Chronic treatment with NSAIDs can also increase the risk of heart attacks, strokes, and other heart problems (17). Please, let your doctor know if there are risk factors that may increase your overall risk, for example, smoking, high blood pressure, high cholesterol, diabetes, or a family history of heart disease.
Some people have found that taking NSAIDs made their psoriasis symptoms worse. Inform your doctor if this happens to you.
Steroid medication (corticosteroids)
Like NSAIDs, corticosteroids can help reduce inflammation and pain (18).
If you have a single painful and/or swollen joint, your doctor may inject the medication directly into the joint. The effect can last from a few weeks to several months. However, having too many steroid injections in the same joint(s) can damage the surrounding tissue and, thus, your doctor will usually not recommend more than three injections per year.
When lots of joints are inflamed, corticosteroids can be taken as a tablet, or as an injection into the muscle. However, doctors are
cautious about this because corticosteroids can cause side effects, such as weight gain and osteoporosis, increased risk of infection and cardiovascular events, if used for long periods of time. Because of these side effects, your doctor will prescribe you the lowest dose necessary to control your symptoms for the shortest time possible. Psoriasis can flare up when you stop using oral corticosteroids.
Disease modifying anti-rheumatic drugs (DMARDs)
DMARDs are powerful medications that reduce inflammation and can stop psoriatic arthritis from getting worse (19). DMARDs can help prevent damage to your joints.
Many DMARDs will treat both psoriasis and psoriatic arthritis. Because this type of medicine treats the cause of your condition and not the symptoms, it can take up to three months before you feel an effect. Therefore, it is important to keep taking the medication, even if it does not seem to be working at first.
Like all drugs, DMARDs can have some side effects. While DMARDs can be very effective, these medications reduce the activity of the immune system (immunosuppressants) and raise the risk of an infection. However, it is important to remember that not treating psoriatic arthritis could lead to permanent bone and joint damage. There are three types of DMARDs as described in Table 1.
Table 1: Types of disease modifying anti-rheumatic drugs.
Traditional
Traditional DMARDs (csDMARDs) have been used the longest and have a broad immune- suppressing effect. These medicines are usually taken by mouth.
Example: methotrexate, sulfasalazine.
Biologic
Biologic DMARDs (bDMARDs) disrupt key steps in the inflammatory process and generally work more quickly than traditional DMARDs. These drugs are usually injected.
Example: adalimumab, etanercept.
Targeted
Like biologic DMARDs, targeted DMARDs (tsDMARDs) block key steps in the inflammatory process. These medications are usually taken by mouth.
Example: tofacitinib.
TREATMENT FOR THE PSORIASIS
The over-the-counter and prescription medicines for psoriasis include:
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topical medications made from vitamin D, derivatives of vitamin A, salicylic acid, coal tar or corticosteroids;
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phototherapy that uses ultraviolet light (UVB) may be prescribed to treat and lessen skin rashes. Only your doctor should prescribe phototherapy, do not try to use sunlight or sunlamps to treat your skin on your own;
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some DMARDs and biological therapies used for arthritis can also help the psoriasis.
VACCINES
If you have psoriatic arthritis, you may have a higher risk of infection and infections may be more severe (20). This can be due to the arthritis itself or its treatment.
Psoriatic arthritis, which caused by a fault of the immune system, can make you more vulnerable to infections. In addition, some of the drugs utilised to treat psoriatic arthritis (e.g., DMARDs and/ or steroids) dampen down the immune system, that is, they act as immunosuppressants, which can also make you more prone to infection.
An increased risk of infection due to a medical condition and/or drugs is called immunosuppression.
Your rheumatologist can provide guidance based on your age and your risk for getting certain infectious diseases (e.g., COVID-19, flu, pneumonia, shingles, or hepatitis B). Vaccines are safe and can help you avoid serious infections.
NON-PHARMACOLOGICAL TREATMENTS
Drugs are not the only way to treat or manage the symptoms of psoriatic arthritis. There are many things you can do, alongside taking prescribed medication, that can improve your life quality by lessening pain and inflammation, and improving your overall health.
YOUR VOICE MATTERS
Your experiences – how your therapies are working, what side affects you are experiencing, how your symptoms are affecting you, what challenges you are facing in your daily life due to psoriatic arthritis – are very important pieces of information.
This information is called patient-reported outcomes (PROs) and it may be collected via a questionnaire prior to your rheumatology appointment. PROs can help your doctor assess the impact of your disease and better evaluate your treatment plan. These questionnaires can also help you self-manage your condition.
Some of the questionnaires your rheumatologist may use are:
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PSAID (Psoriatic Arthritis Impact of Disease): measures the impact of your disease on your physical and psychological health;
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VAS (Visual Analogue Scale): a simple tool to track and measure your pain;
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IPAQ (International Physical Activity Questionnaire): measures the types of intensity of physical activity and sitting time that people do as part of their daily lives;
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HAQ (Health Assessment Questionnaire): measures your physical function and disability due to arthritis;
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FACIT-F (Functional Assessment of Chronic Illness Therapy - Fatigue): measures your fatigue that is caused by the arthritis;
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WPAI (Work Productivity and Activity Impairment): measures impairments in work and activities;
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HADS (Hospital Anxiety and Depression Scale): measures the levels of anxiety and depression;
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PsAQoL (Psoriatic Arthritis Quality of Life): measures the quality of life in people with psoriatic arthritis;
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EQ-5D (EuroQol-5 Dimensions): measures quality of life in relation to 5 dimensions – mobility, usual activities, self-care, pain and discomfort, and anxiety and depression;
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SF-36 (Short Form-36): measures quality of life and covers 8 domains of health – physical functioning, physical role, pain, general health, vitality, social function, emotional role, and mental health.
So, if your doctor or nurse asks you to fill out a questionnaire, please take the time to do it and be honest!
PHYSICAL AND OCCUPATIONAL THERAPY
Inflammation of joints and soft tissues can often lead to extreme pain, immobility, and dysfunction. Additionally, the arthritis can lead to difficulty in daily activities in the home and workplace. Physical and occupational therapy can help you get moving safely and effectively.
Physical therapy is the most impactful if you are experiencing (21):
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loss of motion due to inflammation in the shoulder, wrist, hand, knee, or foot;
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severe enthesitis or dactylitis;
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inflammatory back pain.
Physical therapy will focus on (21):
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improving mobility and restore the use of affected joints;
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increasing muscle strength to support the joints;
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maintaining fitness;
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preserving the ability to perform daily activities.
Occupational therapy can also be helpful, especially if you are experiencing difficulties with everyday activities.
Occupational therapy can help you maximise your ability to participate in daily activities.
Strategies include the use of assistive devices (e.g., braces, splints), and movement modification to help people protect their joints by performing tasks in different ways than they are used to (e.g., using both hands).
SURGERY
Most people diagnosed with psoriatic arthritis will never need joint surgery. However, if joints are severely damaged by the arthritis, or if other treatments do
not reduce pain, damaged joints can be replaced by plastic, metal, or ceramic prosthesis to reduce pain, and improve function and quality of life.
COMPLEMENTARY TREATMENTS
Some people with psoriatic arthritis feel that complementary therapies can be helpful. However, you should always talk to your doctor before trying complementary therapies.
There is no scientific evidence to support that taking any kind of dietary supplement, such as fish body oil capsules, works in treating psoriatic arthritis.
In addition, there is not enough scientific evidence to support the use of complementary therapies, such as balneotherapy or acupuncture, as treatments for psoriatic arthritis.
Complementary therapies can react with other treatments, so you should talk to your doctor if you are using or thinking of using any.
SELF-CARE AND LIFESTYLE
Sedentary behaviour
Sedentary behaviour, characterised by prolonged periods of sitting, when accumulated daily for more than 8 hours or maintained for periods longer than 30 minutes without interruption, constitutes a risk to health and well-being.
In people living with psoriatic arthritis, studies suggest that sedentary behaviour may contribute to increased joint stiffness, reduced muscle strength, and compromised joint function. Additionally, a sedentary lifestyle may exacerbate symptoms such as fatigue and depression, which are common in psoriatic arthritis. While the exact mechanisms are not fully understood, maintaining an active lifestyle is generally considered beneficial for managing psoriatic arthritis symptoms.
The risks of sedentary behaviour increase even more when people are inactive; that is, they do not comply with the World Health Organization’s (WHO) recommendations for physical activity, described below.
Physical activity
Engaging in regular physical activity has been shown to have numerous benefits for people living with psoriatic arthritis. Physical activity concerns all body movements resulting from muscle contraction regardless of the context in which they are carried out: leisure, transportation to and from places, or as part of a person’s work.
Physical activity can help improve joint flexibility, reduce inflammation, and enhance overall joint function. Moreover, physical activity may contribute to better mental health, as it can help alleviate symptoms of depression and anxiety that are often associated with chronic conditions like psoriatic arthritis. Physical activity also plays a role in weight management, which is essential as excess weight can increase joint stress (22).
According to the WHO, it is recommended to accumulate at least ~20 minutes per day of physical activity, such as brisk walking (23). This recommendation is also adopted by the European Alliance of Associations for Rheumatology (24).
A 20-minute physical activity of moderate intensity corresponds to an accumulation of around 2000 steps. Considering a functional activity of 4500 steps per day associated with carrying out activities of daily living such as grooming, cooking, cleaning, travelling to and from work/school, the WHO recommendations, when expressed in total number of steps per day, represent the sum of the two types of activity and correspond to an accumulation of 6500 daily steps under normal living conditions.
Figure 3: Beneficial (on the left side) and harmful (on the right side) dietary patterns. Adapted from Guilliams et al., 2023 (28).
Reducing the intake of sugar, saturated fats, and sodium can help you maintain a healthy weight. Obesity is linked to a higher chance of developing psoriatic arthritis, underlining the significance of weight management, especially for psoriasis patients who often suffer from metabolic syndrome and obesity (29).
Since mechanical stress in the case of an inflammatory crisis can promote the appearance of enthesitis, it is necessary to control inflammation before increasing the level of usual physical activity or starting an exercise programme. In any case, the beneficial effects of physical activity and exercise on disease, well-being and associated comorbidities outweigh the risk of enthesitis induced by mechanical stress, which is low (25).
Diet
While there is no a specific diet that can treat psoriatic arthritis, adopting a nutritious and balanced eating plan can play a vital role in managing symptoms and improving overall wellbeing.
Research suggests that adopting a Mediterranean-style diet (Figure 3, left-hand side), which includes fruits, vegetables, fibre, high-quality fats, and vitamins, might lessen the impact of your psoriatic arthritis (26). This type of diet has anti-inflammatory benefits that help manage
disease activity. So, trying this eating approach might help you ease your psoriatic arthritis symptoms.
Incorporating omega-3 fatty acids, commonly found in oily fish (such as salmon, mackerel, or flaxseeds), can also have anti-inflammatory effects, potentially reducing joint stiffness and tenderness (27).
Antioxidants found in colourful fruits and vegetables (such as berries, spinach, and kale) also offer potent anti-inflammatory properties that could alleviate joint inflammation and discomfort in people living with psoriatic arthritis.
Overall, it is recommended to aim for a balanced intake of 2-5 portions of fruits and 3-5 portions of vegetables daily, as these nutrient-rich foods provide essential antioxidants that may contribute to managing joint inflammation and overall health.
Physical exercise
The most beneficial types of exercise for psoriatic arthritis focus on improving flexibility, strength, and cardiovascular fitness without causing excessive joint stress. Low-impact activities such as swimming, walking, and cycling are often recommended. Strength training exercises, including resistance training and gentle yoga, can help enhance muscle support around the joints.
Water-based exercises are particularly advantageous as they provide buoyancy, reducing impact on the joints. The benefits of these exercises include increased joint mobility, reduced pain and stiffness, improved muscle tone, and better overall well-being.
People living with psoriatic arthritis should adopt a tailored physical activity routine, considering their specific symptoms and limitations.
The iPROLEPSIS app intends to help you limit sedentary behaviours, increase physical activity, and improve daily functional capacity with specific and safe training program recommendations (for more information see section “iPROLEPSIS”).
Excess weight can increase joint discomfort and inflammation, particularly in load-bearing joints (such as the hips, knees, and spine). Thus, be mindful of your dietary choices, as these can help you manage your symptoms.
Vitamin D aids in calcium absorption, which is necessary for maintaining healthy bones. Additionally, vitamin D helps boost our immune system, fight off viruses, and combat fatigue. It has even been linked to good mood, with a deficiency potentially leading to anxiety and depression.
Vitamin D is a fat-soluble vitamin that our bodies produce when the skin is exposed to sunlight. It can also be obtained from certain foods or supplements. This vitamin has several forms, but the most important ones are vitamin D2 (ergocalciferol) and vitamin D3 (cholecalciferol). Vitamin D3 is the form that our skin produces
naturally in response to sunlight. Research indicates that people with psoriatic arthritis often have lower vitamin D levels than others (30).
Having enough vitamin D might help ease some psoriatic arthritis symptoms. The best way to ensure this is through adequate sun exposure. Spending around 10 to 30 minutes in the sun between 10 AM and 3 PM, at least twice a week, is generally sufficient for most individuals to produce enough vitamin D. The exact time needed depends on factors such as skin type, latitude, altitude, and season.
The Medical Board of the National Psoriasis Foundation recommends vitamin D supplementation for psoriatic arthritis patients and encourages overweight or obese patients to explore weight reduction through a controlled diet (31). However, you must seek advice from your doctor.
Hydration is another key aspect often overlooked, but crucial in managing psoriatic arthritis. Though there are no specific hydration guidelines for people with psoriatic arthritis, drinking around two litres of water daily not only supports maintaining overall health (32), but also helps in joint lubrication and efficient functioning, easing discomfort associated with movement.
Some individuals find that certain foods may trigger or exacerbate their psoriatic arthritis symptoms. While these triggers can vary among individuals, common contributors include red and processed meat, low-quality fats, salt and additives, and refined carbohydrates (Figure 3; right-hand side). Monitoring your diet and identifying potential trigger foods through a systematic dietary approach or under the guidance of a healthcare professional can help manage pain, fatigue, and flare-ups (33).
It is essential to find guidance from a healthcare provider or a dietitian with expertise in psoriatic arthritis to develop a personalised dietary plan (28) aligned with individual preferences and needs. A personalised plan aims to guarantee sufficient nutrient intake, manage weight, and promote overall well-being, addressing the unique challenges associated with psoriatic arthritis. Moreover, embracing a healthy lifestyle, including consistent physical activity, stress management, and a well-balanced diet, holds significant potential to improve the quality of life for people with psoriatic arthritis.
Smoking and alcohol consumption
Smoking is bad for your overall health, as it increases the likelihood of potential complications, such as heart problems and cancer. Smoking can also make you less sensitive to treatment and worsen your psoriasis symptoms (34, 35).
Alcohol can interfere with the effectiveness of some drugs or increase side effects (36, 37). Some studies also suggest that alcohol may act as a trigger for flare-ups (38).